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General NPI Number Information
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NPI Number | 1255768818
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Entity Type | Organization
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Legal Business Name | WIDE SMILES MOBILE DENTAL
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Dates
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Enumeration Date | 09/27/2013
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Last Update Date | 09/27/2013
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Provider Practice Location Address
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Address Line | 19332 HUDSON RIVER DR
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City | MACOMB
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State | MI
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Zip | 48044-4241
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Country | US
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Telephone | 586-649-7906
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Fax | 586-231-0118
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Provider Business Mailing Address
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Address Line | 19332 HUDSON RIVER DR
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City | MACOMB
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State | MI
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Zip | 48044-4241
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Country | US
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Telephone | 586-649-7906
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Fax | 586-231-0118
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Authorized Official
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Title or Position | OWNER
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Name | DR. DOUGLAS JOSEPH SHOHA
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Credential | DDS
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Telephone | 586-649-7906
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 16556
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License Number State | MI
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